Welcome to the December 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Cardiology and Critical Care. First of all, we all know that the optimal treatment for STEMI is getting the patient to the cardiac catheterization lab, and time is muscle, but does it help to get patients to the catheterization lab even faster than 90 minutes? Or does speeding up the time have bad outcomes? Secondly, it has been drilled into our heads that high-quality CPR with minimal to no interruptions is key in OHCA. This gives our patients the best chance of neurologically intact survival. But a new study just published might beg to differ. So with that introduction today we are going to specifically tackle:

Background #1: We all know the old adage of “Time is Muscle,” when it comes to management of acute STEMI. Many hospitals have door to balloon (DTB) committees in place to help decrease the time from hospital arrival to onset of reperfusion therapy. A benchmark set by the American College of Cardiology/American Heart Association guidelines is a DTB time of less than 90 minutes for patients presenting with STEMI. There are pressures to decrease these times to even less than 90 minutes, but with less time come more rapid triage decisions with faster dispatches to the catheterization laboratory which may come at an expense of increased false positive STEMI diagnoses and ultimately worse patient outcomes.

What They Did #1:

A Single Center trial of 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization

Instituted an aggressive protocol to reduce door to balloon time

Outcomes were compared before and after initiation of quality improvement measures

Quality Improvement Initiatives Included:

Hospital arrival to electrocardiography (ECG) time of <5minute

Immediate contact with an interventionalist (<5minutes)

After-hours arrival of staff to catheterization laboratory within 30 minutes

An overall DTB time of <60 minutes

Real-time feedback and notes of appreciation given to all the staff involved in cases

Bottom Line #1: All patients, even those with STEMI in the prehospital setting or in triage can benefit from evaluation from an emergency provider. Even if that is a cursory history and physical to make sure that the patient doesn’t have another diagnosis.

Topic #2: Continuous vs Interrupted CPR in OHCA

Question #2: Do continuous chest compressions with asynchronous ventilations or chest compressions interrupted for ventilations during CPR performed by EMS providers affect the rate of survival, neurologic outcome, or the rate of adverse events?

Background #2: In patients with out-of-hospital cardiac arrest (OHCA), the interruption of cardiopulmonary resuscitation (CPR) for rescue breathing has been thought to decrease cerebral and coronary perfusion pressure and therefore decrease survival with good neurologic outcomes. One way to get around these pauses is to provide asynchronous ventilations while not pausing CPR.

ROC sites grouped into 47 clusters which were randomly assigned in a 1:1 ratio

Twice per year each cluster was crossed over to the other resuscitation strategy

Continuous CPR Group = Chest compressions at a rate of 100 compressions/minute with asynchronous positive-pressure ventilations delivered at a rate of 10 ventilations/minute

Interrupted CPR Group = Chest compressions at a rate of 100 compressions/minute with interruptions for ventilations at a ratio of 30:2 (pauses in compressions <5 seconds duration)

Bottom Line #2: If high quality CPR is performed, with a high chest compression fraction early in cardiac arrest, this study shows that there is no difference if continuous CPR vs interrupted CPR is used on survival with favorable neurological recovery.

For More Details of the above Studies Checkout the December 2015 REBELCast Show Notes

This is a big study with big researchers. More than my opinions, I would love to hear from some of the authors of this study Drs. Cheskes, Vallincort, Calloway, Christenson to name a few. The ROC consortium has most of the rockstars of OOHCPR research that have led this discussion. I love how this group doing a study not to prove another group/person wrong but to test their own ideas, test their own data and test their own conclusions in order to find truth. We have refined standard OOHCPR care to the point where we are really fine tuning and splitting hairs (important hairs) to find the best practice. Just look at how well these patients were resuscitated: The compression fraction in this study is amazing. (77%-83%) In comparison to historical studies, stopping CPR for <5 seconds could be argued by many to not even be much of a pause? It just shows how far we have grown in this area. I wonder what changes these great researchers and clinicians will make in their practices, given the mountain of work they have done in the past and in light of this new data?